Effect of maternal hyperoxygenation on neonatal outcomes among women in labour with pathological cardiotocography: an open-label randomized controlled trial

BACKGROUND

Hyperoxygenation has shown promise in improving suspicious fetal heart patterns in women in labor. However, the effect of hyperoxygenation on neonatal outcomes in women in labor with pathologic fetal heart rate tracing has not been studied.

OBJECTIVE

This study aimed to evaluate the effect of fractional inspiration of oxygen of 80% compared with fractional inspiration of oxygen of 40% on neonatal outcomes in women with pathologic fetal heart rate tracing.

STUDY DESIGN

This randomized, open-label, parallel arm, outcome assessor-blinded clinical trial was conducted in a large tertiary care university hospital. Singleton parturients aged ≥18 years at term gestation in active labor (cervical dilatation of ≥6 cm) with pathologic fetal heart rate tracing were recruited in the study. Pathologic fetal heart rate tracing was defined according to the International Federation of Gynecology and Obstetrics 2015 guidelines. The International Federation of Gynecology and Obstetrics classifies fetal heart rate tracings into 3 categories (normal, suspicious, and pathologic) based on rate, variability, and deceleration. Women in the intervention arm received oxygen at 10 L/min via a nonrebreathing mask, and those in the usual care arm received oxygen at 6 L/min with a simple face mask. Oxygen supplementation was continued until cord clamping. The primary outcome measure was a 5-minute Apgar score. The secondary outcome measures were the proportion of neonatal intensive care unit admission, umbilical cord blood gas variables, level of methyl malondialdehyde in the cord blood, and mode of delivery.

RESULTS

Overall, 148 women (74 women in the high fractional inspiration of oxygen arm and 74 in the low fractional inspiration of oxygen arm) with pathologic fetal heart rate tracing were analyzed. The demographic data, obstetrical profiles, and comorbidities were comparable. The median 5-minute Apgar scores were 9 (interquartile range, 8-10) in the hyperoxygenation arm and 9 (interquartile range, 8-10) in the usual care arm (P=.12). Furthermore, the rate of neonatal intensive care unit admission (9.5% vs 12.2%; P=.6) and the requirement of positive pressure ventilation (6.8% vs 8.1%; P=.75) were comparable. Concerning cord blood gas parameters, the hyperoxygenation arm had a significantly higher base deficit in the umbilical vein and lactate level in the umbilical artery. The cesarean delivery rate was significantly lower in women who received hyperoxygenation (4.1% [3/74]) than in women who received normal oxygen supplementation (25.7% [19/74]) (P=.00). In addition, umbilical vein malondialdehyde level in the umbilical vein was lower in the hyperoxygenation group (8.28±4.65 μmol/L) than in the normal oxygen supplementation group (13.44±8.34 μmol/L) (P=.00).

CONCLUSION

Hyperoxygenation did not improve the neonatal Apgar score in women with pathologic fetal heart rate tracing. In addition, neonatal intensive care unit admission rate and blood gas parameters remained comparable. Therefore, the results of this trial suggest that a high fractional inspiration of oxygen supplementation confers no benefit on neonatal outcomes in women with pathologic fetal heart rate tracings and normal oxygen saturation.

Comparison of digital and speculum-guided methods of transcervical Foley catheter insertion in primigravida undergoing cervical ripening at term gestation: a noninferiority randomized clinical trial

BACKGROUND

Foley catheter insertion is frequently used for cervical ripening during the induction of labor. However, the insertion failure, safety, maternal side effects, complications, and satisfaction of digital compared with speculum-guided Foley catheter placement have not been evaluated in a large trial involving primigravida.

OBJECTIVE

The study aimed to compare the insertion failure rate of digital and speculum-based transcervical Foley catheter placement in primigravida. The co-primary outcome was insertion-associated pain. The secondary outcomes were the time required for successful insertion, maternal satisfaction, and maternal complications within 24 hours of Foley insertion.

STUDY DESIGN

This randomized, open-label, parallel-arm, noninferiority clinical trial was performed in a large tertiary care university hospital. Primigravida aged >18 years with term gestation (≥37 weeks) were included in this study. Additional inclusion criteria for enrollment in this study were singleton pregnancy with a cephalic presentation, intact membrane, a Bishop score of ≤5, and reassuring preinduction fetal heart rate tracing. All women planned for cervical ripening were assessed for eligibility and were randomized into digital or speculum arms. Foley catheter insertion was performed in a supine lithotomy position. Vaginal and cervical cleaning were performed before insertion. A 22-French Foley balloon catheter was guided digitally or via speculum to position the bulb at the level of the internal os using water-soluble lubricant. Insertion-associated pain was measured using a visual numeric rating scale, and maternal satisfaction was assessed using a set of questions.

RESULTS

Four hundred and sixty-nine pregnant women were assessed for eligibility, and 446 patients were enrolled and randomized. The median age of the parturients was 24 (19-40) and 24 (18-38) years, respectively. The body mass index, gestational age at randomization, the incidence of postdated pregnancy, and prerandomization Bishop scores were comparable. Insertion failure was observed in 24 (10.8%) and 17 (7.6%) women in digital and speculum arms, respectively (relative risk=1.41 [95% confidence interval, 0.78-2.55]; P=.25). Requirements of >1 attempt (5.4% vs 3.6%) followed by the change in hands (3.6% vs 2.7%) were the most common reasons for insertion failure. The median (interquartile range) visual numeric rating scale was comparable (6 [2-9] vs 5 [2-10]; P=.15). The time taken for successful insertion was similar (58 [12-241] vs 54 [10-281]; P=.30). 9.4% and 10.8% of women required additional methods of cervical ripening. More women in the speculum group (41.7% vs 33.2%; P=.06) felt a medium level of discomfort than the digital group.

CONCLUSION

Insertion failure and insertion-related pain in the digital approach were comparable to the speculum-guided approach for transcervical Foley catheter insertion in primigravida for cervical ripening. Nevertheless, maternal satisfaction was higher in the digital group because of a lesser level of discomfort.

Thoracic organ transplantation and pregnancy outcomes: systematic review and meta-analysis

PURPOSE

Pre-conceptual comorbidities, an inherent risk of graft loss, rejection during pregnancy, and the postpartum period in women with thoracic lung transplant may predispose them to increased risk of adverse feto-maternal outcomes. The study aimed to systematically analyze and assess the risk of adverse pregnancy outcomes in women with thoracic organ transplant.

METHODS

MEDLINE, EMBASE, and Cochrane library were searched for publication between January 1990 and June 2020. Risk of bias was assessed using Joanna Briggs critical appraisal tool for case series. The primary outcomes included maternal mortality and pregnancy loss. The secondary outcomes were maternal complications, neonatal complications, and adverse birth outcomes. The analysis was performed using the DerSimonian-Laird random effects model.

RESULTS

Eleven studies captured data from 275 parturient with thoracic organ transplant describing 400 pregnancies. The primary outcomes included maternal mortality {pooled incidence (95% confidence interval) 4.2 (2.5-7.1) at 1 year and 19.5 (15.3-24.5) during follow-up}. Pooled estimates yielded 10.1% (5.6-17.5) and 21.8% (10.9-38.8) risk of rejection and graft dysfunction during and after pregnancy, respectively. Although 67% (60.2-73.2) of pregnancies resulted in live birth, total pregnancy loss and neonatal death occurred in 33.5% (26.7-40.9) and 2.8% (1.4-5.6), respectively. Prematurity and low birth weight were reported in 45.1% (38.5-51.9) and 42.7% (32.8-53.2), respectively.

CONCLUSIONS

Despite pregnancies resulting in nearly 2/3rd of live births, high incidence of pregnancy loss, prematurity and low birth weight remain a cause of concern. Focused pre-conceptual counseling to avoid unplanned pregnancy, especially in women with transplant-related organ dysfunctions and complications, is vital to improve pregnancy outcomes.

PROSPERO NUMBER

CRD42020164020.

Tremor Induced by Cyclosporine, Tacrolimus, Sirolimus, or Everolimus: A Review of the Literature

Calcineurin inhibitors such as cyclosporine and tacrolimus are immunosuppressant drugs that are known to induce tremors. Non-calcineurin inhibitors such as sirolimus and everolimus have also reportedly been accompanied by tremors, albeit less likely. However, the prevalence rates reported in the literature are notably wide, and the risk profiles for these drug-induced tremors are less understood. We searched PubMed to extract data on the risk of tremors with these drugs when prescribed for various transplant and non-transplant indications. We ascertained whether the risk of drug-induced tremor is influenced by the underlying diagnosis, dosing formulations, drug concentrations, and blood monitoring. We extracted data on treatment strategies and outcomes for tremors. Articles were primarily screened based on English language publications, abstracts, and studies with n ≥ 5, which included case series, retrospective studies, case-controlled studies, and prospective studies. We found 81 eligible studies comprising 33 cyclosporine, 43 tacrolimus, 6 sirolimus, and 1 everolimus that discussed tremor as an adverse event. In the pooled analysis of studies with n > 100, the incidence of tremor was 17% with cyclosporine, 21.5% with tacrolimus, and 7.8% with sirolimus and everolimus together. Regarding the underlying diagnosis, tremor was more frequently reported in kidney transplant (cyclosporine 28%, tacrolimus 30.1%) and bone marrow transplant (cyclosporine 40%, tacrolimus 41.9%) patients compared with liver transplant (cyclosporine 9%, tacrolimus 11.5%) and nontransplant indications (cyclosporine 21.5%, tacrolimus 11.3%). Most studies did not report whether the risk of tremors correlated with drug concentrations in the blood. The prevalence of tremors when using the twice-daily formulation of tacrolimus was nearly the same as the once-daily formulation (17% vs 18%). Data on individual-level risk factors for tremors were lacking. Except for three studies that found some benefit to maintaining magnesium levels, there were minimal data on treatments and outcomes. A large body of data supports a substantive and wide prevalence of tremor resulting from tacrolimus use followed by cyclosporine, especially in patients receiving a kidney transplant. However, there is little reporting on the patient-related risk factors for tremor, risk relationship with drug concentrations, treatment strategies, and outcomes.

Fetomaternal outcome of scarred uterine rupture compared with primary uterine rupture: a retrospective cohort study

OBJECTIVES

Literature comparing maternal and perinatal outcomes among women with scarred and primary uterine rupture are limited. Therefore, the study aimed to compare maternal and perinatal outcomes and associated risk factors of uterine rupture among scarred and unscarred uterus.

METHODS

This retrospective cohort study was performed at a large tertiary care of India between July 1, 2011 and June 30, 2020. We analysed all the cases of complete uterine rupture beyond the 20th week of gestation. The outcome measures were live birth rate, perinatal mortality, maternal mortality and morbidity.

RESULTS

A total of 115 complete uterine ruptures were noted in 148,102 pregnancies. Of those 115 uterine ruptures, 89 (77.3 %) uterine ruptures occurred in women with a history of caesarean delivery, and 26 (22.6 %) uterine ruptures occurred in primary uterine rupture. The primary uterine rupture group had a significantly higher incidence of lower parity, breech presentation and mean birth weight. The live birth rate (68.18% vs. 42.85 %; p=0.04) was significantly higher in the scarred group, and the stillbirth rate (57.14% vs. 31.86 %; p=0.009) was significantly higher in the primary uterine rupture group. Hypoxic ischemic encephalopathy, APGAR score, and neonatal intensive care unit admission were comparable. Postpartum haemorrhage, blood transfusion, severe acute maternal morbidity and intensive care unit stay were more frequently reported in the primary uterine rupture group.

CONCLUSIONS

The maternal and perinatal outcomes appear less favourable among women with primary uterine rupture than scarred uterine rupture.

The Role of Cross-Sectional Imaging in the Diagnosis of Agenesis of the Dorsal Pancreas: A Case Series

Background Agenesis of the dorsal pancreas is a rare entity and is caused due to the defective embryological development of the pancreas. The clinical manifestations may range from diabetes mellitus, pancreatitis, and abdominal pain to no symptoms at all. We here present a case series of 10 cases with complete or partial agenesis of the dorsal pancreas. Objectives To correlate the clinical symptoms in the patients with the dorsal agenesis of the pancreas, to study any biochemical abnormality present with the dorsal agenesis of the pancreas, and to look for other coexistent finding in the patients. Results We observed that out of 10 patients, six were males and four were females. Four had symptoms related to the pancreas and six were discovered incidentally. Diabetes mellitus was present in five patients, seven patients had pain in the abdomen, and jaundice was seen in three patients. Out of 10 patients, four had complete agenesis and six had partial agenesis of the dorsal pancreas. Conclusions We conclude that the diagnosis of this rare entity and establishing its association with clinical conditions like diabetes mellitus and non-specific abdomen pain with the aid of cross-sectional imaging helps in the better evaluation and management of the patients.

Barriers and facilitating factors of postnatal blood glucose monitoring after structured intervention among mothers with gestational diabetes mellitus receiving care from a tertiary health centre, Puducherry - A qualitative study

BACKGROUND

In India, women with GDM are at an increased risk of developing type 2 diabetes mellitus (T2DM). Despite this, the rate of postnatal blood glucose monitoring is low, and the reasons are not well known. Hence, our study explored the barriers and facilitating factors associated with T2DM postnatal screening six weeks after delivery.

MATERIALS AND METHODS

We conducted a qualitative study among 21 mothers with GDM in obstetrics and gynecology department, women and child hospital (WCH), JIPMER, from December 2021 to January 2022. Mothers with GDM were selected purposively between 8 and 12 weeks after delivery to explore the barriers and facilitating factors associated with postnatal screening six weeks after getting mobile call reminders and health information booklet interventions. In-depth interviews were transcribed; manual content analysis with deductive and inductive coding was done.

RESULTS

We identified two themes; three categories and subcategories that illustrated barriers and five categories that illustrated facilitators to postnatal blood glucose monitoring. Lack of awareness and misconceptions about GDM, knowledge practice gap, lack of family support, and perception of health system failure by mothers with GDM were barriers to postnatal blood glucose monitoring. Concerns about health, standard advice on postnatal screening, information in health education booklet, mobile reminders, and family support were found to be facilitators.

CONCLUSION

We found several barriers and facilitating factors that showed mobile call reminders and booklet interventions had improved postnatal blood glucose monitoring. Our qualitative study has strengthened the findings of the previous RCT, and it would provide more insights to develop further interventions which we must focus on improving postnatal blood glucose monitoring.

Management and outcomes of pulmonary artery hypertension and Eisenmenger syndrome during pregnancy: a prospective observational cohort study

OBJECTIVES

Maternal-fetal morbidity and mortality among pregnant women with pulmonary artery hypertension (PAH) and Eisenmenger syndrome are unacceptable, and management decision-making in these clinical scenarios remains debatable. This study aimed to compare and analyse clinical characteristics, management and pregnancy outcomes in PAH and Eisenmenger syndrome.

DESIGN

Prospective observational cohort study.

SETTINGS

A large tertiary care university hospital.

PATIENTS

Thirty patients with pulmonary artery hypertension and 20 patients with Eisenmenger syndrome.

METHODS

Data pertaining to clinical characteristics, anaesthetic, medical and obstetric management, and outcomes in pregnancy complicated by PAH and Eisenmenger syndrome were collected between July 2020 and June 2022. Each treating unit followed its management protocol in consultation with the multidisciplinary team.

MAIN OUTCOME MEASURES

Maternal mortality and morbidity.

RESULTS

Maternal mortality was lower in the PAH group (6.6% versus 15%; p = 0.33). All mortalities were in the postpartum period. The incidence of new-onset or exacerbation of heart failure (23.3% versus 60%; p = 0.009) and hypoxaemia (13.3% versus 50%; p = 0.005) were significantly lower in the PAH group. In the Eisenmenger syndrome group, a significantly higher number of women received pulmonary hypertension and heart failure medications. Prematurity and neonatal intensive care unit admission were frequently noticed in Eisenmenger syndrome, whereas perinatal mortality, birthweight and APGAR score were comparable.

CONCLUSIONS

Fetomaternal outcomes are inferior in Eisenmenger syndrome compared with PAH and are either lower or comparable to those reported from contemporary cohorts of developed nations.

Clinical characteristics, predictors and pregnancy outcomes in Indian women with peripartum cardiomyopathy

Background

Predictors, pregnancy and subsequent pregnancy outcomes in women with peripartum cardiomyopathy (PPCM) are poorly understood in our geographical region.

Methods

We retrospectively analysed 58 women with PPCM diagnosed using criteria by the European Society of Cardiology during 2015 to 2019. The main outcome measures were predictors of left ventricular (LV) recovery. LV recovery was defined as return of LV ejection fraction to over 50%.

Results

Nearly 80% of women had LV recovery during 6 months follow up. Univariate logistic regression revealed LV end diastolic diameter (adjusted odds ratio (OR); 0.87; 95% CI, 0.78-0.98; p = 0.02), LV end systolic diameter (OR; 0.89; 95% CI, 0.8-0.98; p = 0.02) and inotrope use (OR; 0.2, 95% CI, 0.05-0.7; p = 0.01) as predictors of LV recovery. Relapse was not seen in any of the nine women who had a subsequent pregnancy.

Conclusion

LV recovery was higher than those reported in contemporary PPCM cohorts from other parts of the world.

Perioperative Decision-Making in Pulmonary Hypertension

Pulmonary hypertension (PH) is a haemodynamic manifestation of cardiorespiratory and non-cardiorespiratory pathologies. Cardiorespiratory pathologies account for nearly three-fourths of patients with PH. It is now increasingly being recognised due to routine requests for transthoracic echocardiographic examination in the perioperative setting in patients undergoing intermediate- to high-risk non-cardiac surgery. The increased risks of perioperative morbidity and mortality attributed to PH have been widely acknowledged in the literature. The importance of PH in perioperative decision-making and postoperative outcomes has had little mention in all the guidelines. Understanding the complexity of the pathophysiology of PH may help in anaesthetic and surgical decision-making. Preoperative evaluation and risk assessment are guided by the nature, extent, invasiveness, and duration of surgery. Surgical decision-making and anaesthetic management involve preoperative risk stratification, understanding the interactions between surgical procedures and PH, and understanding the interactions between anaesthetic procedures, PH, and cardiopulmonary interactions. Intraoperative and postoperative monitoring is crucial for maintaining the haemodynamic parameters and helps titrate anaesthetic agents and medication. This narrative review focusses on all issues related to anaesthetic and surgical challenges in patients with PH. This review aimed to suggest a preoperative evaluation plan, surgical decision-making, anaesthetic plan, and anaesthetic management based on the evidence available in the literature.

Malignant Epidermoid Cyst: MRI Evaluation and Review of Literature

Epidermoid cysts are commonly encountered intracranial neoplastic masses in clinical radiology practice. They are purely benign but may undergo malignant transformation or may present as de novo malignant epidermoid tumor, a rare but ominous phenomenon associated with poor prognosis. Malignant epidermoids may masquerade as glial tumours, ependymal neoplasms, or choroid plexus masses, and are prone to be misdiagnosed. We describe a case of malignant epidermoid cyst or tumor (de novo) in a young adult who presented with the complaints of intermittent headaches which had increased in frequency and severity.

Diagnosis, management and outcomes of primary hypokalemic periodic paralysis during pregnancy

Primary hypokalaemic periodic paralysis during pregnancy has been rarely reported. Four pregnant women with the acute onset of flaccid paralysis presented between January 2018 and December 2021. Focussed history and physical examination helped an appropriate radiological and laboratory investigation plan to be made. All women recovered within 4–7 days of potassium supplementation. Supplemental potassium continued until delivery. A pain management plan with continuous epidural infusion helped in avoiding stress-induced hypokalaemia. None of the women developed an episode of muscle weakness during the intervening period. In conclusion, a focussed history and targeted laboratory investigation are needed to diagnose primary hypokalaemic periodic paralysis. Early administration of oral or intravenous potassium is crucial in improving fetomaternal outcomes.

Undiagnosed and Uncontrolled Hypertension and Access to Health Care among Residents of an Urban Area of Eastern Nepal: a Cross-sectional Study

Background The burden and complication of hypertension is increasing as most of the people living with hypertension are unaware of their condition and those who are already diagnosed with it do not have their blood pressure under control. Objective To assess the prevalence of undiagnosed and uncontrolled hypertension among residents of Itahari sub metropolitan city of eastern Nepal, along with its associated socio demographic and behavioral risk factors and access to health care services. Method Cross sectional study was conducted in five wards of Itahari, among 1161 participants, using population proportionate to sample size sampling technique. Face to face interview was conducted with participants for data collection applying semi- structured questionnaire and physical measurement like blood pressure, weight and height. Result Prevalence of hypertension was 26.5% includingundiagnosed 11.0% and previously diagnosed 15.5%. Among diagnosed, 76.6% had uncontrolled blood pressure and 56.70% were taking anti-hypertensive medicine, and 7.8% were under Ayurvedic medicine. More than 70% participants preferred private health facility for treatment and 22.7% had faced financial barrier to seek healthcare. About 64% of participants did not visit health services or had visited only once in past six months. Increasing age, Body Mass Index (BMI), smoking status and positive family history were found to be significantly associated with hypertension at < 0.05 level. Conclusion Prevalence of hypertension is high and awareness regarding available health services in local primary health center and its utilization is lacking among participants. Regular screening program for hypertension and awareness program to disseminate the knowledge of availability of primary health center should be conducted.

A Point Prevalence Study of the Use of Antibiotics in Six Tertiary Care Hospitals in the Kathmandu Valley, Nepal

Background Point prevalence survey (PPS) on antibiotic use developed by the WHO has already been used in many hospitals globally. Objective To obtain information on antibiotic prescribtion using point prevalence survey methodology in six private hospitals in the Kathmandu valley. Method This descriptive cross-sectional study was completed during 20th July to 28th July 2021 using point prevalence survey methodology. The study was conducted among inpatients admitted at or before 8:00 AM on the day of survey in various wards. Data was presented as frequencies and percentages. Result Maximum number of patients were above 60 years [34 (18.7%)]. Number of male and female participants were equal [91 (50%)]. Only one antibiotic was used in 81 patients (44.5%) followed by two antibiotics in 71 (39%) patients. Duration of prophylactic antibiotic use was one day in 66 (63.7%) patients. Blood, urine, sputum, and wound swabs were the common samples for culture. Cultures were positive for 17 (24.7%) samples. The common organisms isolated were E. Coli, Pseudomonas aeruginosa and Klebsiella pneumoniae. Ceftriaxone was the most used antibiotic. Drug and therapeutics, infection control committee and pharmacovigilance activities were present in 3/6 (50%) study sites. Antimicrobial stewardship was present in 3/6 (50%) and microbiological services was present in all hospitals. Antibiotic formulary and antibiotic guideline were present in 4/6 sites and facilities to audit or review surgical antibiotic prophylaxis choice in 2/6 (33.3%) sites, facility to monitor antibiotic use in 4/6 (66.6%) and cumulative antibiotic susceptibility reports in 2/6 (33.3%) study sites. Conclusion Ceftriaxone was the most used antibiotic. E. Coli, Pseudomonas aeruginosa and Klebsiella pneumonia were the commonly isolated organisms. Not all parameters for infrastructure, policy and practice and monitoring and feedback were present at the study sites. KEY WORDS.

Effectiveness of Mobile Call Reminders and Health Information Booklet to Improve Postnatal Blood Glucose Monitoring among Mothers with Gestational Diabetes Mellitus Receiving Care from a Tertiary Health Centre, Puducherry - A Randomized Controlled Trial

BACKGROUND

In India, around 10% of mothers with gestational diabetes mellitus (GDM) develop diabetes within months after delivery. But only 29% of them undergo blood glucose testing in the postnatal period. Our study aimed to compare the proportion of mothers with GDM who got postnatal blood glucose checked at 8 weeks among mothers who received health education booklets and mobile reminders.

METHODS

We conducted a randomised controlled trial among 165 mothers with GDM receiving care from a tertiary health centre between January 2020 and June 2021. Mothers with GDM in the intervention 1 arm received a health education booklet in the third trimester, those in intervention 2 arm received mobile call reminders at the fourth and fifth weeks postpartum, control arm received standard care advised in the hospital; they were followed up at 8 weeks postnatally. We used Chi-square test to compare the effectiveness of intervention and standard care. Relative risk with a 95% confidence interval was calculated to measure the strength of association. A P value <0.05 was considered statistically significant.

RESULTS

A total of 161 participants (97.58%) completed the study; Out of 55 mothers with GDM in each arm, 30 (56.60%) in the booklet arm, 23 (42.59%) in the mobile reminder arm, and 13 (24.07%) in the standard care arm had undergone postnatal blood glucose monitoring at 8 weeks. There was a statistically significant difference in the postnatal blood glucose monitoring in the booklet arm (RR: 2.21 [1.35-3.64], P value <0.002) compared to the control arm, but the difference was not significant in the mobile reminder arm (1.65 [0.96-2.86], P value 0.072).

CONCLUSION

Health education booklet and mobile call reminders effectively improved postnatal visit compliance compared to standard care. We can diagnose mothers with GDM progressing to diabetes in the postnatal period by implementing these interventions.

Human Resources for Cardiovascular Disease Management in Nepal: A National Need Assessment

Background Human resources are the mainstay of the healthcare system. Higher numbers of health workers have better healthcare coverage and outcomes. Availability of trained human resources to address the exponential rise in cardiovascular disease in Nepal is a national concern. Objective To assess the need of human resources for cardiovascular disease management in Nepal. Method We conducted an exploratory sequential mixed-method study. We developed a task force and organized a national workshop to engage stakeholders and collect feedback on the research process. We did a desk review and conducted 24 key informant interviews. We did thematic analysis from the codes generated. Result There is no clear definition and required estimation of health workers for cardiovascular disease management. There is a shortage of health workers with 8.9 doctors, 20.8 nurses, 0.05 cardiologist/cardiac surgeon, 4.2 pharmacist, 10.2 laboratory technicians per 10,000 population. There is a comprehensive human resource plan but it does not provide details of human resources for cardiovascular disease management. There is a lack of public private collaboration for human resource management. However, there is production of human resources for cardiovascular disease management through pre-service specialized courses and inservice training. Conclusion A clear definition and estimation of health workers with stringent human resource plan for cardiovascular disease management is essential. The government can still address these gaps by establishing a well-equipped central health workforce unit and expanding collaboration with private sectors.

Medical Products for Cardiovascular Disease Management in Nepal: a needs assessment study

Background Medical Products and Technologies is a key component of the health system. Quality medicines and efficient management of the medical products can secure effective cardiovascular diseases management. Objective To collate information and identify strengths, weaknesses, opportunities and threats (SWOT) associated with medical products and technology component for cardiovascular disease management in Nepal. Method This study is a part of a larger rapid assessment of Nepal's health system for cardiovascular disease management and based on The Health System Assessment Approach: A How-To Manual (USAID). The authors conducted a desk review of documents related to the WHO "medical product and technology" building block component and key informant interviews using a pre-tested interview protocol. The first eight interviews were transcribed verbatim and analysed inductively to generate a codebook; and the remaining, transcribed and deductively coded based on the codebook. Findings were categorised into relevant topical area and SWOT components. Result Nepal has laws and provisions for medicine regulation, pharmacovigilance, post marketing surveillance, registration and licensing provisions for pharmacy industries/ outlets, essential medicine lists and national formulary. These provisions also apply to medicines used for cardiovascular diseases. The challenge however, is the lack of effective implementation and monitoring, due to shortages of technical workforce and state of art information and technologies. Information on pharmaceutical expenditures for cardiovascular disease management is scarce; there are no standard national level guidelines that are consistently used to manage cardiovascular diseases in health facilities. Conclusion There are limited provisions and information on medical products for cardiovascular disease management in Nepal, and a need to strengthen existing provisions for medicine regulations and surveillance.

Assessment of Health Service Delivery to Address Cardiovascular Diseases in Nepal

Background A health care delivery system is the organization of people, institutions, and resources designed to deliver health services. A comprehensive study to explore cardiovascular health service delivery in Nepal is lacking. Objective This study attempted to assess Nepal's health system gap on organization and delivery of cardiovascular disease prevention and management services. Method This mixed-method study used the six building blocks of the World Health Organization health system framework: organization; access; coverage, utilization and demand; equity; quality of services; and outcomes. We conducted the desk reviews of national and international documents, performed several key informant interviews, calculated the relevant indicators, and assessed the Strengths, Weaknesses, Opportunities, and Threats of the cardiovascular health service delivery. Result We found that most of the cardiovascular services are concentrated in urban areas, and suffer from poor access, quality, utilization, and coverage in most of the areas resulting in poor health outcomes. Though the services have recently improved due to increased primary care interventions, there is scope for the development of competent human resources, advancement of technologies, development of national protocols, and improved monitoring and supervision. Improved disease system including the medical recording and reporting mechanism to incorporate and reflect the true burden of CVD in Nepal is lacking. Conclusion Despite having health facilities from grassroots to the central level, availability, access, and quality of cardiovascular health services are poor. Further improvement and equitable expansion of promotive, preventive, diagnostic, referral, and rehabilitative cardiovascular services are needed to ensure universal health coverage.

Needs Assessment of Leadership and Governance in Cardiovascular Health in Nepal

Background Good governance and leadership are essential to improve healthy life expectancy particularly in low and middle-income countries (LMICs). This study aimed to epitomize the challenges and opportunities for leadership and good governance for the health system to address non-communicable diseases particularly cardiovascular diseases (CVD) in Nepal. Objective The objective of this study was to understand and document CVD programs and policy formulation processes and to identify the government capacity to engage stakeholders for planning and implementation purposes. Method A national-level task force was formed to coordinate and steer the overall need assessment process. A qualitative study design was adopted using "The Health System Assessment Approach". Eighteen indicators under six topical areas in leadership and governance in cardiovascular health were assessed using desk review and key informant interviews. Result Voice and accountability exist in planning for health from the local level. The government has shown a strong willingness and has a strategy to work together with the private and non-government sectors in health however, the coordination has not been effective. There are strong rules in place for regulatory quality, control of corruption, and maintaining financial transparency. The government frequently relies on evidence generated from large-scale surveys for health policy formulation and planning but research in cardiovascular health has been minimum. There is a scarcity of cardiovascular disease-specific protocols. Conclusion Despite plenty of opportunities, much homework is needed to improve leadership and governance in cardiovascular health in Nepal. The government needs to designate a workforce for specific programs to help monitor the enforcement of health sector regulations, allocate enough funding to encourage CVD research, and work towards developing CVD-specific guidelines, protocols, and capacity building. KEY WORDS Cardiovascular diseases, Governance, Leadership, Needs assessment, Nepal.

National Needs Assessment of Health Information System to Address Cardiovascular Diseases in Nepal: A Mixed Method Study

Background Health financing is a major domain of health system building blocks. With the epidemiological transition and increasing trend of Cardiovascular diseases (CVDs), it is crucial to assess the status of health financing to address the gap of prevention, control, and treatment of CVDs in Nepal. Objective This paper aims to assess the situation of healthcare financing on Cardiovascular diseases in Nepal. We framed three key functions of health system financing: (a) revenue collection, (b) pooling of resources, and (c) purchasing of services for this study. Method We used sequential explanatory mixed-method research design. We conducted desk reviews, analyzed secondary data on health financing followed by Key-Informant Interviews with five relevant policymakers and experts between February and September 2019. We obtained the Ethical clearance from the Nepal Health Research Council. Result Out of pocket (OOP) expenditure remains the highest source (52%) of total health care expenditure in Nepal, and two third of it is made for NCDs. Out of total current health expenditure on outpatient and inpatient services for fiscal year 2015/16, only 7% of total NCDs was spent on CVDs. Hypertension is the third-most utilized insurance service out of 36 CVD related services provided by the Health Insurance Board. The existing health related social service schemes covers the high costs associated with treatment, and streamlining these services including provider payment mechanisms with the health insurance program could open up opportunities to expand quality CVD services and make it accessible to the marginalized population. Conclusion Health Financing is the integral part of the health system. With the rising burden of cardiovascular diseases and its impact on impoverishment due to high OOP, integrated health care services, budget specification based on the evidence-based burden of disease such as CVD needs to be prioritized by the government.

National Needs Assessment of Health Information System to Address Cardiovascular Diseases in Nepal: A Mixed Method Study

Background Health information system is an integral component of a country's capacity to integrate, process, report, and use information in improving health services. Objective This study aims to assess the infrastructure and capacity of the national Health information system to address cardiovascular diseases in Nepal. Method We adopted the United States Agency for International Development manual "The Health System Assessment Approach: A How-To Manual", Version 2.0. Three topical areas: input, process and output, were identified. Stepwise approach for Health information system assessment was done. A desk review and key informant interview was performed. Audio recordings were transcribed in Nepali language and intercoder reliability was checked. Result The upgraded District Health Information Software 2.3 provides a comprehensive online data management solution. Sustainable funding to upgrade the system exists. Annual report provides performance of all the components of the health care delivery system. Data were reviewed quarterly. However, no dedicated section for cardiovascular diseases in the Health information system is present. Private health facilities are poorly represented. Strategic planning, management, and evaluation of the Health information system are lacking. Inadequacy of timeliness, completeness, and periodicity of the reporting still exist. Conclusion A separate section of cardiovascular diseases in the Health information system is required. Better reporting of private sectors and its inclusion in databases is of utmost importance. Adaptation in the recently introduced federal structure is key for development of Health information system in the country.

Subsequent Pregnancy Outcome in Women with Prior Complete Uterine Rupture: A Single Tertiary Care Centre Experience

Limited data is available to assess the burden of maternal morbidity, mortality, and perinatal outcome after subsequent pregnancy in women with prior uterine rupture. Therefore, this retrospective descriptive study was conducted to determine subsequent pregnancy outcomes in a larger series of women with prior complete uterine rupture. All pregnant women who had complete uterine rupture were managed according to the standard Institute protocol. The women who conceived following a uterine repair from July 2011 to June 2020 were recruited into the study. Outcome measures included severe maternal morbidities and perinatal outcomes. Fifty-three women with prior complete uterine rupture were conceived subsequently. Two women had an abortion in the first and second trimester, respectively. None of the women developed recurrence of uterine rupture. However, three women developed uterine dehiscence in a total of 16 women who went into spontaneous labour before elective cesarean delivery at 32, 36, and 37 weeks, respectively. None of the women had placenta previa, placenta accreta, bowel injury, bladder injury and none required a hysterectomy. However, 16.7% of women needed a blood transfusion. None of the women required mechanical ventilation, inotropic support, and intensive care unit stay. Seventeen babies required neonatal intensive care admission, and prematurity (90%) was the most common reason, followed by low APGAR scores. In conclusion, subsequent pregnancy outcomes in women with prior uterine rupture appear acceptable in institutionalized care. Timing of cesarean delivery may have to be weighed against the risk of prematurity-associated neonatal morbidity and mortality.

Achieving organizational effectiveness of MNCs through People: Evidence from India and Mozambique

Purpose

The purpose of this study is to provide human resource (HR) practitioners of multinational companies aspiring to invest in these two countries with guidelines for attaining organizational effectiveness through people.

Design/methodology/approach

This study develops and tests a multiple criteria decision-making model with data collected in the banking sectors of India and Mozambique. It compares the job engagement, team building and innovation strategy preferences of Indian personnel with those of Mozambican employees.

Findings

The findings of the study reveal the differences in the perceptions of the respondents of both countries regarding the importance of the strategies for organizational effectiveness.

Research limitations/implications

Despite several contributions, the study has certain limitations too. Although utmost care was taken to avoid the issue of common method variance, the cross-sectional self-reported design of the study might be adversely affected by common method bias (MacKenzie and Podsakoff, 2012). Hence, future research might be conducted using different designs, such as diary studies or longitudinal studies. Future research might also be conducted making use of organizational productivity case studies to demonstrate the practicability of customizing the HR strategies using the multi-attribute decision-making approach.

Practical implications

This body of work is an addition to the existing literature on cross-national studies in the field of HR management (HRM) and adds to the limited literature on HRM in the least developed countries. The study is designed to provide guidelines for the HR practitioners of multi-national companies in these two countries to help them achieve enhanced organizational effectiveness. This should be of particular interest to the HR managers of the Indian companies aspiring to invest in Mozambique.

Originality/value

Research in the area of HRM is mainly limited to the developed and developing nations, with very few studies centering on emerging economies. While most cross-national studies on organizational effectiveness are also largely focused on developed and developing nations, this study is unusual, in that its focus is on a fast-developing nation (India) and an emerging economy (Mozambique).

Time in range, as measured by continuous glucose monitor, as a predictor of microvascular complications in type 2 diabetes: a systematic review

Continuous glucose monitoring (CGM)-derived time in range (TIR) correlates with hemoglobin A1c (A1c) among patients with type 2 diabetes mellitus (T2DM); however, there is a paucity of data evaluating its association with microvascular complications. We conducted this systematic review to examine the association between TIR and microvascular complications of diabetic retinopathy (DR), diabetic nephropathy (DN), and diabetic peripheral neuropathy (DPN). We conducted a comprehensive literature search on PubMed, Scopus, and Web of Science online databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text original articles that evaluated the association between CGM-derived TIR and risk of microvascular complications and were published between 2010 and June 2021 were included in our systematic review. The quality of the included studies was evaluated using the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were analyzed using qualitative synthesis. Eleven studies on a total of 13 987 patients were included in the systematic review. The median sample size, baseline A1c, and diabetes duration were 466 patients (range: 105-5901), 8.2% (SD 0.5%), and 11.3 years (1.0), respectively. Majority of the studies were conducted in Asia (10 out of 11). Four studies evaluated the relationship between CGM-derived TIR and DR and CGM-derived TIR and DN, while seven studies evaluated the relationship between CGM-derived TIR and DPN. A 10% increase in TIR was associated with a reduction in albuminuria, severity of DR, and prevalence of DPN and cardiac autonomic neuropathy. In addition, an association was observed between urinary albumin to creatinine ratio but not with estimated glomerular filtration rate. This review summarizes recent evidence supporting an association between CGM-derived TIR and microvascular complications among patients with T2DM. A larger-scale multicenter investigation that includes more diverse participants is warranted to further validate the utility of TIR as a predictor of diabetic microvascular complications.

A Rare Type of Uterine Rupture Following Over-the-Counter Use of Misoprostol in Second Trimester Abortion

The use of misoprostol in the second trimester by a woman with a uterine scar may lead to severe contractions and uterine rupture. We report a 24-year-old pregnant female patient who presented at the Emergency Department at a tertiary care hospital in Puducherry, India, in 2020 with haemorrhagic shock. She was at 16 weeks of gestation and had taken over the counter misoprostol for inducing an abortion. A quick initial resuscitation and urgent laparotomy were performed. An irreparable circumferentially avulsed uterus suspended only by round ligaments was noted. Haemostasis required internal artery ligation and immediate total hysterectomy. The patient was doing well upon follow-up six months after the surgery. Proper and supervised use of misoprostol in the appropriate dosage can avoid life-threatening consequences of uterine rupture.

Dermatologic Manifestations of Endocrine Disorders

Endocrine disorders are known to involve all organ systems of the body, including the skin. The cutaneous manifestations of endocrine disorders can range from common findings such as acanthosis nigricans, pretibial myxedema, acne, hirsutism, hyper or hypopigmentation to rare cutaneous findings such as miliaria rubra, calciphylaxis, lentigines, and calcinosis cutis. These cutaneous symptoms can sometimes be the presenting symptoms or can even be pathognomonic of the underlying endocrine condition. In some cases, the cutaneous symptoms from an underlying endocrine abnormality may be the most prominent. These symptoms can significantly affect the quality of life of individuals. Often, individuals may seek health care from a dermatologist or primary care physician for isolated skin symptoms. Therefore, it is imperative for physicians to recognize the skin symptoms as the manifestation of the endocrine disorder for prompt diagnosis and treatment of the underlying endocrine disorder.

Fever, cough and gastrointestinal symptoms in a pregnant woman

Despite distinct diagnostic criteria, several gastrointestinal pathologies can masquerade haemophagocytic lymphohistiocytosis (HLH) during the peripartum period. Acute fatty liver of pregnancy, HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome, miliary tuberculosis, visceral leishmaniasis, abdominal surgical emergencies, haemolytic anaemias and haematological malignancies may have clinical and laboratory presentation similar to that of HLH. In this report, we present the case of a 26-year-old woman with 38-weeks' gestation and abdominal pain, vomiting, intermittent fever and non-productive cough for 1-2 months. A thorough investigation suggested HLH and the patient was successfully treated with corticosteroids. This patient demonstrates the importance of a focused investigation strategy and timely management to prevent mortality and morbidity to both the mother and fetus in this rare and fatal disease.

Atypical neurological manifestations in Wernicke's encephalopathy due to hyperemesis gravidarum

OBJECTIVES

Hyperemesis gravidarum is known to induce nutritional, water and electrolyte deficiencies which can be fatal if not treated urgently. Thiamine deficiency may lead to a constellation of neurological symptoms that include Wernicke encephalopathy. Moreover, Wernicke encephalopathy is typically manifested as ocular paresis, ataxia and confusion.

METHODS

Retrospective review of 6 women who developed neurological abnormalities following hyperemesis gravidarum and were treated with varying dosage of parenteral thiamine.

RESULTS

Five women developed atypical neurological symptoms, namely, slurred speech, visual loss, seizure and aggressive behaviour while one woman developed typical clinical triad of Wernicke encephalopathy after hyperemesis gravidarum. Magnetic Resonance Imaging (MRI) scans revealed abnormalities suggestive of Wernicke encephalopathy in three women only. All women improved after parenteral thiamine administration during hospital stay and had a complete neurological recovery during 2 months follow up.

DISCUSSION

Wernicke encephalopathy may not be necessarily associated with the typical neurological triad and may not have noticeable hyperintensity signal in dorsomedial thalami, mammillary bodies, hippocampus and periaqueductal region during magnetic resonance imaging. Atypical neurological signs and symptoms following hyperemesis gravidarum would invariably respond immediately to appropriate dosage of parenteral thiamine. A lower loading dosage of thiamine (100 mg thrice daily) appeared adequate for management in women with normal MRI scans.

Probiotic characterization of bacterial strains from fermented South Indian tomato pickle and country chicken intestine having antioxidative and antiproliferative activities

AIM

The present study aims to evaluate the potential antioxidant and antiproliferative properties of probiotic bacterial isolates Weissella cibaria p3B, Bacillus subtilis CS, and Bacillus tequilensis CL, isolated from South Indian fermented tomato pickle (homemade) and gut content of indigenous country chicken.

METHODS AND RESULTS

The bacterial isolates exhibited antimicrobial activity against food-borne, human pathogenic bacteria, along with better survival under different bile and acidic conditions, hydrophobicity towards several hydrocarbons, and adherence to intestinal epithelial cells (INT-407 cells). Also, the intact cell (IC) mixture of the three species showed better DPPH, ABTS, and Fe²⁺ chelating activity as compared to the individual IC or cell extract (CE) activity. Among the three bacterial species, W. cibaria p3B revealed maximum antiproliferative activity against HeLa and Caco-2 cancer cells, all of which were nontoxic to INT-407 cells. Apart from being non-hemolytic, the bacterial isolates did not display any necrotic inhibition in HeLa and Caco-2 cells. The cell free supernatant (CFS) of the three bacterial isolates were tested for the production of antimicrobial peptides or bacteriocins. It found that the CFS of bacterial isolates was stable at various temperature, pH and sensitive to proteolytic enzymes confirms protenoius in nature of the antimicrobil peptides or bacteriocins.

CONCLUSION

The bacterial isolates showed promising antimicrobial, antioxidant as well as antiproliferative activities with better survival ability at different pH and bile concentrations. The three bacterial isolates were able to produce potential antimicrobial peptides or bacteriocins.

SIGNIFICANCE AND IMPACT OF THE STUDY

These results indicate better compatibility of our bacterial isolates against synthetic drugs to avoid adverse side effects and can be processed as dietary supplements against food and human pathogens. They can also provide antioxidative and antiproliferative benefits to humans and animals.

Peripartum cardiomyopathy

Peripartum cardiomyopathy is now increasingly recognized as a cause of heart failure in the later months of pregnancy and early postpartum period. Clinical diagnosis may be challenging as it closely resembles several common medical and obstetric complications. Complex pathogenesis, unpredictable onset, staggered recovery, and unanticipated fetomaternal risks pose unique challenge to clinicians. Prevalence seems to vary with race, geographic location, and diagnostic criteria. The presence of multiple risk factors substantially elevates the risk of PPCM. Transthoracic echocardiographic examination can exclude the majority of the mimickers. Symptomatic presentation is initially limited to, varying grades of low cardiac output syndrome. Rarely, PPCM begins with decompensated heart failure and cardiovascular collapse. Guideline-directed medical therapy involves graded initiation and titration of heart failure medications while ensuring the fetal and neonatal safety. Anesthetic and obstetric management should be individualized to improve fetomaternal outcomes. However, emergent cesarean delivery may be required in women with decompensated heart failure and cardiovascular collapse. An early institution of mechanical circulatory support has shown to improve outcome. Bromocriptine and other experimental drugs designed to target pathogenic pathway have yielded mixed results. A further change in approach to management requires a comprehensive understanding of pathophysiology and fetomaternal safety profiles of heart failure medications.

Automated Detection of TMJ Osteoarthritis Based on Artificial Intelligence

The purpose of this study was to develop a diagnostic tool to automatically detect temporomandibular joint osteoarthritis (TMJOA) from cone beam computed tomography (CBCT) images with artificial intelligence. CBCT images of patients diagnosed with temporomandibular disorder were included for image preparation. Single-shot detection, an object detection model, was trained with 3,514 sagittal CBCT images of the temporomandibular joint that showed signs of osseous changes in the mandibular condyle. The region of interest (condylar head) was defined and classified into 2 categories-indeterminate for TMJOA and TMJOA-according to image analysis criteria for the diagnosis of temporomandibular disorder. The model was tested with 2 sets of 300 images in total. The average accuracy, precision, recall, and F1 score over the 2 test sets were 0.86, 0.85, 0.84, and 0.84, respectively. Automated detection of TMJOA from sagittal CBCT images is possible by using a deep neural networks model. It may be used to support clinicians with diagnosis and decision making for treatments of TMJOA.

Employee voice, engagement and organizational effectiveness: a mediated model

Purpose

This study is based on social exchange theory and aims at understanding the role of employee engagement as a mediator between employee voice and organizational effectiveness.

Design/methodology/approach

Data was collected to test the mediating role of employee engagement between employee voice and organizational effectiveness. The respondents were employees in different IT companies located in major cities in India. The model was tested for full and partial mediation of employee engagement using structural equation modeling.

Findings

Considering the self-reported survey from 232 employees from companies in the IT sector, the findings reveal that there exists a significant association between employee voice and organizational effectiveness. The results reflect a close association between employee engagement and organizational effectiveness too. However, no significant association was found between employee voice and organizational effectiveness. Employee engagement is found to mediate the relationship between employee voice and organizational effectiveness.

Research limitations/implications

The foremost limitation of the study is the sample group that is limited to employees working in IT companies in Bangalore city. The results cannot be generalized to the entire IT industry in India. Although attempts are made to eliminate common method bias, there are chances of an overstated relationship by common method variance that cannot be neglected completely.

Practical implications

The paper will provide a deep insight to the practitioners about the role of employee voice in the engagement of employees. It will also indicate to the managers how the effectiveness of an organization can be heightened by creating opportunities for employees to voice their opinion in the organization.

Originality/value

The present study indicated that though there is an association between the independent variable, employee voice, and the dependent variable, organizational effectiveness, the relationship becomes more significant in the presence of employee engagement between them.

Effect of Irradiance and Exposure Duration on Temperature and Degree of Conversion of Dual-Cure Resin Cement for Ceramic Restorations

This study investigated the effects of irradiance and exposure duration on dual-cured resin cements irradiated through ceramic restorative materials. A single light-curing unit was calibrated to three different irradiances (500, 1000, and 1500 mW/cm²) and irradiated to three different attenuating materials (transparent acryl, lithium disilicate, zirconia) with 1-mm thicknesses for 20 or 60 seconds. The changes in irradiance and temperature were measured with a radiometer (or digital thermometer) under the attenuating materials. The degree of conversion (DC) of dual-cure resin cement after irradiation at different irradiances and exposure durations was measured with Fourier transform near infrared spectroscopy. Two-way analysis of variance revealed that irradiance ( p<0.001) and exposure duration ( p<0.001) significantly affected temperature and DC. All groups showed higher DCs with increased exposure times ( p<0.05), but there were no statistically significant differences between the groups irradiated with 1000 mW/cm² and 1500 mW/cm² ( p>0.05). Higher-intensity irradiances yielded higher temperatures ( p<0.05), but exposure time did not affect temperature when materials were irradiated at 500 mW/cm² ( p>0.05).

Maternal and Fetal Outcome After Cardiac Operations During Pregnancy: A Meta-Analysis

BACKGROUND

In the past, cardiac surgical procedures during pregnancy have been associated with a high risk of adverse maternal and fetal outcomes. Therefore, this meta-analysis of more recent studies was done to assess the fetomaternal risk after cardiac operations during pregnancy using cardiopulmonary bypass.

METHODS

The MEDLINE, Embase, and Cochrane library were searched to find studies from January 1, 1990, to July 31, 2016, without language restriction. We selected studies that included at least 4 women to report fetomaternal outcomes after a cardiac operation using cardiopulmonary bypass during pregnancy. Two authors independently extracted data from the selected studies. The studies were assessed for methodological qualities using the Newcastle-Ottawa Scale. The primary outcomes included maternal death and any pregnancy loss. The secondary outcomes were maternal complications and neonatal complications. Primary analysis calculated absolute risks and 95% confidence intervals (CIs) for pregnancy outcomes using the DerSimonian-Laird random effects model. Heterogeneity was assessed by I² statistic and visual plot.

RESULTS

Ten studies, including 154 women, were eligible for inclusion in this study. The patients underwent cardiac operations during pregnancy involving cardiopulmonary bypass. As calculated per 100 pregnancies, the pooled unadjusted estimate of maternal mortality was 11.2 (95% CI, 6.8 to 17.8), pregnancy loss was 33.1 (95% CI, 25.1 to 41.2), maternal complications were 8.8 (95% CI, 2.8 to 24.2), and neonatal complications were 10.8 (95% CI, 4.2 to 25.2). The risks of preterm labor and cesarean delivery were 28 per 100 pregnancies (95% CI, 15.6 to 45) and 33.8 per 100 pregnancies (95% CI, 19.1 to 52.4), respectively.

CONCLUSIONS

The fetomaternal mortality and morbidity after a cardiac operation during pregnancy are higher than that reported in the earlier literature (PROSPERO No. CRD42016047093).

Knowledge, Attitude and Practice Regarding Pharmacovigilance and Consumer Pharmacovigilance among Consumers at Lalitpur District, Nepal

BACKGROUND

Adverse drug reactions (ADRs) can be a big threat to the health of people in Nepal as a variety of medicines are consumed in the country. Involving consumers in pharmacovigilance can strengthen ADR reporting. The study aims to find out knowledge, attitude and practice regarding pharmacovigilance and consumer pharmacovigilance among consumers at Lalitpur district, Nepal Methods: It was carried out in outpatients visiting in KIST Medical College and Teaching Hospital, Lalitpur, Nepal. Participant's knowledge, attitude and practice were measured by noting their agreement with a set of 21 statements along with multiple choice and open ended questions.

RESULTS

A total of 157 outpatients were surveyed. The knowledge scores for males (12) was better compared to the females (11), but the scores for attitude and practice were same for both groups. The maximum score for knowledge was 29, attitude was 6 and practice was 10. The overall KAP scores was 45. The total scores for knowledge, attitude and practice for males (24) were better compared to female (22) respondents. Seventy-one patients (68%) who participated in this study favoured establishing a consumer centre for obtaining information about ADRs.

CONCLUSIONS

Knowledge scores among consumers regarding pharmacovigilance is low and require advocacy and improvement.

Epidemiological Study of Tobacco Smoking Behaviour amongst Residents of the Hill Region of Nepal

Background Tobacco use is still a serious public health problem in the world and represents a major cause of morbidity and mortality in most parts of the world. Objective To measure the prevalence of tobacco use and to identify the factors associated with tobacco use among the residents of Dhankuta Municipality. Method The cross-sectional study was conducted among the residents of the Dhankuta Municipality where 205 households were taken as subjects. Pretested semistructured questionnaire was used for data collection and face to face interview was conducted. Univariate and multivariate logistic regression was used to see the association between various factors and tobacco use and identify the predictor variables. Result Overall prevalence of tobacco consumption in Dhankuta Municipality was found to be 57.1%. Prevalence of tobacco consumption among the male was significantly higher (67%) than female (47.1%) (p<0.05). Most of the respondents (56.4%) started consuming tobacco due to peer pressure and for recreation (24.8%). The multivariate logistic regression showed that the people with illiterate have higher chances of consuming tobacco than above School Leaving Certificate (OR 38.395, 95% CI=3.209- 459.417). The respondents below poverty line (<1.25 US$) was consuming tobacco more than above poverty line (> 1.25 US $) (OR 6.814, 95% CI= 1.255-36.986). Conclusion The aims of this study was to measure the prevalence of tobacco use and to identify the factors associated with tobacco use among the residents of the Dhankuta Municipality. We conclude that the prevalence rate of tobacco consumption in the Dhankuta Municipality was found to be moderately high. Factors like male in gender, Brahmin/Chhetri in ethnicity, lack of education, poor occupation like farmer and housewife, poor economic status were associated with tobacco use.

Aetioepidemiological profile of spinal injury patients in Eastern Nepal

This is a retrospective case series of 233 spinal injury patients admitted to the orthopaedic ward of BPKIHS from May 1997 to April 2001. The inpatient records were analysed. In all, 40.3% of spinal injuries resulted from falls from trees while cutting leaves for fodder, and 27.9% resulted from falls from first/second floors. More than 75% of total spinal injuries are largely preventable. Overall, 46.8% of our spinal injury patients had complete cord transection at the level of injury. All adolescents and adults, irrespective of age or sex, should be the target groups for community education and intervention programmes for prevention of spinal injury.

An Assessment of Diabetic Retinopathy and Diabetes Management System in Nepal

BACKGROUND

Visual damage due to diabetic retinopathy is a major concern which can be reduced through appropriate coordination and cooperation between the diabetes management services and diabetic retinopathy services. The study assessed the existence, availability and accessibility of health care services for diabetes mellitus and diabetic retinopathy in Nepal.

METHODS

The study was carried out from 1 April to 24 June 2015. The tool for assessment of diabetic retinopathy and diabetes management systems developed by the World Health Organization was used for the assessment of major stakeholders like endocrinologists, ophthalmologists, ophthalmic assistants, nurses involved in diabetes care, patients and human resources from Ministry of Health and Population and international non-governmental organizations dealing with eye care services in Nepal.

RESULTS

Thirty-seven key stakeholders were selected for the study. Six out of fifteen ophthalmologists were unaware about the prioritization of diabetes as national health concern. The main function of diabetes association included patient education and awareness 18(48.6%), clinician education and awareness 16(43.2%). Thirteen professionals (35.1%) said that the patients were not found to be aware about diabetic patients' organizations. The information to community is provided occasionally and only through national-level media. All forms of diabetes care were funded out-of-pocket by the patients themselves.

CONCLUSIONS

Coordination should be strengthened for an effective and holistic management of diabetes mellitus making diabetes care and diabetic retinopathy services more accessible. Diabetes mellitus and its complications are becoming a public health threat in Nepal.